"A community’s physical form, rather than its land uses, is its most intrinsic and enduring characteristic." [Katz, EPA] This blog focuses on place and placemaking and all that makes it work--historic preservation, urban design, transportation, asset-based community development, arts & cultural development, commercial district revitalization, tourism & destination development, and quality of life advocacy--along with doses of civic engagement and good governance watchdogging.

Sunday, June 21, 2015

DC's fire department is in the same situation as WMATA in terms of the necessity of a redesign of culture and behavior through a human factors approach

Washington Post photo.

In addition to the FTA report on WMATA released earlier in the week, a similarly scathing report was released by the DC Auditor about the DC Fire and Emergency Services, which since the 2006 death of David Rosenbaum, because of a series of mis-steps by department personnel, has experienced a similar ongoing cycle of ever escalating failures and more unnecessary deaths.

D.C. Auditor Kathleen Patterson issued a report Thursday that found of the 36 recommendations made by the Rosenbaum Task Force — chief among them to have all first responders cross-trained with basic firefighting and medical skills — only 11 have been fully implemented.

The task force was convened in 2007 to recommend fixes for the city’s Fire and Emergency Medical Services Department after it was found that a neglectful, botched emergency response contributed to the 2006 death of New York Times journalist David Rosenbaum, who had suffered a head wound after being beaten and robbed.

One more thing, Brookland activist Dan Wolkoff has made the point for many years that because so many of the emergency calls are to deal with drunks, DCFEMS personnel come to believe that almost anyone they attend to is likely to be an alcoholic. In all likelihood that's why Mr. Rosenbaum was misdiagnosed as they misinterpreted his symptoms as the result of drunkenness rather than from a beating, fall, and subsequent head injury.

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For the most part, the text below is a repeat from the WMATA-related entry from a couple days ago. It's repeated because it is equally relevant and the same process of human factors related redesign should be applied to DCFEMS.
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About 20 years ago, New Yorker Magazine ran a great piece about the bureaucracy and dysfunction in the Chicago Post Office ("LOST IN THE MAIL"). My sense is that DCFEMS operations are roughly at the same level of dysfunction.

The New Statesman explains the human factors approach in the context of how after the death of his wife from an avoidable error, an airplane pilot is working with the British National Health service to apply airplane safety and crash analysis protocols to health care to reduce errors and deaths. From the article:

In the 1990s, a cognitive psychologist called James Reason turned this principle into a theory of how accidents happen in large organisations. When a space shuttle crashes or an oil tanker leaks, our instinct is to look for a single, “root” cause. This often leads us to the operator: the person who triggered the disaster by pulling the wrong lever or entering the wrong line of code. But the operator is at the end of a long chain of decisions, some of them taken that day, some taken long in the past, all contributing to the accident; like achievements, accidents are a team effort. Reason proposed a “Swiss cheese” model: accidents happen when a concatenation of factors occurs in unpredictable ways, like the holes in a block of cheese lining up.

James Reason’s underlying message was that because human beings are fallible and will always make operational mistakes, it is the responsibility of managers to ensure that those mistakes are anticipated, planned for and learned from. Without seeking to do away altogether with the notion of culpability, he shifted the emphasis from the flaws of individuals to flaws in organisation, from the person to the environment, and from blame to learning.

The science of “human factors” now permeates the aviation industry. It includes a sophisticated understanding of the kinds of mistakes that even experts make under stress. So when Martin Bromiley read the Harmer report, an incomprehensible event suddenly made sense to him. “I thought, this is classic human factors stuff. Fixation error, time perception, hierarchy.”

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About Me

I am an urban/commercial district revitalization and transportation/mobility advocate and consultant and a principal in BicyclePASS, a bicycle facilities systems integration firm, based in Washington, DC. Urban economic competitiveness is dependent on efficient transit and mixed use, compact places. Therefore, I end up writing mostly about mobility and urban design. While I am based in and write about Washington, DC issues, I try to write so that "universal lessons" are evident in the entries.